ABC of labour care

Obstetric emergencies
Geoffrey Chamberlain, Philip Steer
The management of emergencies is usually the responsibility of
hospital obstetricians. As more maternity care is now given in
the community, however, midwives, general practitioners, and
paramedics may be involved and must know the outlines of
management of emergencies and the possible side effects. If
such a situation occurs outside the hospital then arrangements
must be made to transport the woman to the obstetric unit
safely and promptly.
All emergency protocols should have been considered
beforehand and mutually agreed by obstetricians, midwives,
general practitioners, and paramedics. Everybody then knows
their immediate priority, and hazards to the woman can be
minimised.
Abruption of the placenta
An abruption is a death threat to the fetus and a hazard to the
mother. When the placenta separates from its bed (probably
because of the rupture of a malformed blood vessel), the
damage to the fetus follows not just because of the barrier that
the clot makes between the placental bed and villi but also
because the release of prostaglandins causes a major degree of
uterine spasm. This interferes with perfusion of the placenta,
which remains attached. Blood tracking into the myometrium
often goes as far as the peritoneum over the uterus, causing
much pain and shock, with spasm of the uterine muscle.
In major degrees of placental abruption the woman is
shocked well beyond the apparent amount of blood loss and
needs urgent transport into hospital. A wide bore intravenous
line should be set up and blood sent for cross matching of at
least six units of blood. Until this blood arrives, other plasma
expanding fluids, such as Haemaccel, should be used.
If the fetus is still alive and gestation sufficiently advanced,
caesarean section is the best management. However, if the fetus
is dead, conservative management can be pursued provided
that the woman does not continue deterioratingfor example,
by developing a coagulopathy. Most women with a severe
abruption that kills the fetus will go into spontaneous labour
soon and have an easy delivery, but caesarean section is
occasionally necessary for maternal indications alone.
Treatment must be aimed at the shock and at preventing
disseminated intravascular coagulopathy.
Usually the placenta is implanted on the anterior wall of the
uterus, but sometimes it is posterior when the abruption is less
painful and not so severe that the mother is shocked; the fetus
may still be at risk, however. Diagnosis in these cases is by
recognition of the excessively frequent contractions produced
by the prostaglandin release and the abnormal pattern of the
fetal heart rate secondary to fetal hypoxia; these are best shown
with cardiotocography, a priority investigation in all women
admitted with abdominal pain in pregnancy.
Placenta praevia
The blastocyst occasionally implants in the lower part of the
uterus. Stretching and thinning of the uterine muscle of the
lower segment in the third trimester may sheer off part of the
placental attachment. This is accompanied by painless bleeding.
The first principles of dealing with
obstetric emergencies are the same as for
any emergency (see to the airway,
breathing, and circulation), but remember
that in obstetrics there are two patients;
the fetus is very vulnerable to maternal
hypoxia
Clinical features of abruption of the placenta
Symptoms
x Abdominal pain
x Severe shock with symptoms beyond vaginal blood loss
x Vaginal bleedingusually old blood
Signs
x Shock
x Spasm of uterusdescribed as woody
x Tender uterus
x Fetal parts hard to feel
x Often no fetal heart is heard
Emergency treatment of abruption
Treat the shock
x Give oxygen
x Insert intravenous lines
x Arrange a cross match of 6 units of blood
x Give morphine (if fetus dead)
Deliver the fetus
x By caesarean section (if fetus is alive and gestation is mature)
x By rupturing membranes (if cervix is ripe or fetus is dead)
Treat disseminated intravascular coagulopathy
x Urgent haematological consultation
x Check platelet count
x Give cryoprecipitate (fresh frozen plasma)
x Transfuse with fresh blood if available
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Fetal heart rate
Contraction of uterus
Cardiotocograph during an abruption of placenta (arrow indicates sudden
abdominal pain)
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Often the fetus is not affected by the first small bleeds, but
they should be taken seriously for there is a risk that the mother
could have a much larger bleed. Hence, women with bright red,
painless vaginal bleeding are considered to have placenta
praevia until proved otherwise and should be admitted to
hospital. Vaginal ultrasound examination is the best technique
for investigating possible placenta praevia, but, although it has a
high sensitivity and specificity for central placenta praevia in the
third trimester, it is much less precise in the late second
trimester or for marginal placenta praevia. Management should
therefore always be based on appropriate clinical judgment.
If placenta praevia is confirmed the woman should stay in
hospital for at least 48 hours after the bleeding has stopped.
Management is conservative, even to the level of giving blood
transfusions for severe bleeds, until the fetus is mature (at about
36 weeks). Studies do not show any benefit in keeping women
in hospital until delivery, provided that they have a telephone at
home and live close enough to the hospital to be brought in by
the emergency services within 20 minutes if they start bleeding
again (Love et al, 1996). Unless it is very obviousfor example,
a complete placenta praevia on ultrasound examination,
together with a transverse lie of the fetusplacenta praevia is
sometimes confirmed by examination under general
anaesthesia in theatre, proceeding in most instances to
caesarean section performed by a senior obstetrician.
Occasionally, if the placenta is anterior and only just engaging
in the lower segment, the membranes may be ruptured and a
vaginal delivery expected, as the head coming down into the
mothers pelvis will compress the bleeding placental bed against
the back of the pubis symphysis. The same cannot be said for
any degree of posterior placenta praevia.
After delivery, a postpartum haemorrhage is likely because
the placental bed is situated over less well contracting uterine
muscle and may well bleed despite oxytocic stimulation. This
often requires blood transfusion.
Postpartum haemorrhage
After a normal delivery a woman commonly loses up to 300 ml
of blood. As her blood volume has increased because of fluid
retention during pregnancy, this is a loss which can be coped
with readily. However, a loss of >500 ml measured clinically in
the first 24 hours is considered to be a primary postpartum
Clinical aspects of placenta praevia
Symptoms
x Vaginal bleedingbright red, painless, recurrent
Signs
x Soft, pain free uterus
x Easy to feel fetusoften high head, breech, or transverse lie
x No fetal distress
Do not do a digital vaginal examination
A speculum examination in an inpatient to exclude any local bleeding
is acceptable
Stage I Stage II
Stage III
Type I
Type II
Type III
Type IV
Classical Classifications
Marginal
Lateral
Central
Contemporary
Minor
Major
Ultrasound
Stage IV
Four stages of severity of placenta praevia: Iplacenta encroaches on lower
segment but does not reach internal os; IIplacenta reaches internal os but
does not cover it; IIIplacenta covers internal os before dilatation but not
when dilated; IVplacenta completely covers internal os even when dilated
Sacrum
Rectum
Fetal head
1
2
1
2
3
Placenta
Bladder drawn up into abdomen
Pubis
a) b)
4
5
6
1
3 3
4
4 5 5
6 6
2
Descending head can compress anterior placenta praevia against pubis (left)
but not posterior sited placenta (right) as too much soft tissue intervenes
Ultrasound picture of placenta praevia. A=fetal head; B=anterior uterine
wall; C=full bladder; D=placenta; E=placental lakes; F=cervical canal
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haemorrhage. Blood loss is commonly underestimated by the
attending practitioners. The mother should be watched carefully
and treatments given to prevent any further loss.
If the uterus has not contracted firmly, manual stimulation
may work by rubbing up a contraction, and a further oxytocic is
given. If the placenta is incomplete the uterine cavity is
explored for the remaining lobules whose presence in the
uterine cavity may prevent the organ contracting down. If
neither of these conditions exists, trauma to the lower uterus,
cervix, or upper vagina may be the cause of the bleeding. Such
traumas should be looked for (in theatre with a good light) and
sutured appropriately. A rare cause of continuing primary
postpartum haemorrhage is a rupture of the uterus. This needs
diagnosis and treatment with either hysterectomy or abdominal
resuturing.
After the first 24 hours, any bleeding is a secondary
postpartum haemorrhage. It is commonly associated with
infection, which should be treated vigorously with intravenous
antibiotics. If it persists, suction evacuation of the uterus should
be undertaken by a senior obstetrician; perforation of the soft
uterus is a major risk in this situation.
A complication of severe and prolonged blood loss is a
consumptive coagulopathy, when the mothers blood does not
clot owing to interference with the clotting cascade. The
continuing cooperation of a senior haematologist is essential.
The mother continues to bleed not just from the placental bed
but from other sites in the body. This needs firm and prompt
correction so that full coagulation can be restored. Giving
cryoprecipitate (frozen precipitate) provides the missing
components.
Amniotic fluid embolism
Occasionally, when the uterus is contracting strongly and there
is an opening between the amniotic sac and the uterine veins, a
bolus of amniotic fluid is pumped into the circulation. This
passes through the heart, and an accumulation of amniotic cells
becomes trapped in the pulmonary circulation. The amniotic
fluid may cause local disseminated intravascular coagulation,
which may spread. This rare condition can occur late in the last
trimester or during labour.
Amniotic fluid embolism used to be diagnosed on histology
only after a postmortem examination but is now sometimes
diagnosed before death. The symptoms include collapse while
having strong contractions, shock without any blood loss,
sudden dyspnoea, and the production of frothy sputum.
Treatment is supportive, with steroids, intravenous plasma
expansion, and urgent delivery. This obstetric emergency is rare
and has a bad prognosis for both mother and fetus, usually
owing to delay in diagnosis.
Inversion of uterus
Very rarely, if misapplied pressure has been used on the uterine
fundus or traction on the cord of a non-separated placenta in a
multiparous woman, the uterus can dimple and invert. This is a
very shocking event as the fundus turns inside out and goes
through the cervix into the vagina. Treatment requires an
experienced obstetrician, who will try to return the uterus
under general anaesthesia. This can be very difficult.
Infection
After delivery the genital tract has several sites of potential
ingress of bacteria. The placental bed itself is a large raw area,
Management of primary postpartum haemorrhage
Preventive
x Intramuscular oxytocin at the end of the second stage of labour
Curative
x Repeat oxytocic administration
x Rub up a contraction
x Check completeness of the placentaif it is not delivered or a
lobule is missing, prepare for manual removal
x Bimanual compression
x Intramyometrial prostaglandin E
2
or carboprost
x Surgical ligationuterine arteries, internal iliac arteries, or braces
(or Lynch) suture of uterus
x Hysterectomy
Process Clotting cascade Clinical condition
Endothelial injury XII XIIa
XI XIa
IX IXa
X Xa
II IIa
Fibrinogen Fibrin
Pre-eclampsia
Hypovolaemia
Septicaemia
Abruption of placenta
Amniotic fluid embolism
Retained dead fetus
Placenta accreta
Thromboplastin Septicaemia
Phospholipid Intravascular haemolysis
Large fetomaternal bleed
Septicaemia
Mechanisms of blood clotting, and some of the clinical conditions that act at
various points of the cascade to interfere with clotting
Uterus
Fallopian tube
Pelvic abscess -
Pouch of Douglas
Bladder
Episiotomy site
Breast
6
1
2
3
4
5
1
2
3
4
5
6
Commonest sites of postpartum infection
Cervix
Fundus of uterus
Vagina
Acute inversion of uterus
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and ascending infection from the lower genital tract may be
assisted by previous intrauterine proceduresfor example,
forceps delivery. Infection of the cervix or, uncommonly, of the
episiotomy site, may also occur; the breast can also be a site of
infection in the puerperium.
Psychological conditions
Pregnancy and childbirth are times of high psychological
stimulation. Any pre-existing psychological disorder may be
exaggerated at this time and requires treatment. Many women
go through mood swings (blues) in relation to childbirth, which
can usually be managed by sympathetic support. If postnatal
depression persists for a week or so, mild antidepressants may
be needed, and the Edinburgh postnatal depression
questionnaire may be helpful in diagnosing the condition. If the
condition continues, formal psychiatric help is needed.
At the extreme of the spectrum of disease a puerperal
psychosis may occur; both the mother and her baby should be
admitted to a dedicated maternity/psychiatric unit as both are
at risk. Here the mother can have expert psychiatric nursing
and medical care while looking after her own baby. There is a
25% risk of recurrence in a future pregnancy.
Stillbirth and intrauterine death
In Britain 3-4 babies per 1000 are stillborn and another 3-4 per
1000 die in the first week of life. The grief reactions in both the
woman and her partner need careful management by the
midwifery and medical staff. The couple may go through a
phase of anger; all hospital and community staff should be
trained to cope with this. Midwifery and medical staff must be
prepared to listen and offer their sympathies without attributing
blame.
Parents should be encouraged to agree to a postmortem
examination of the fetus and placenta by a skilled paediatric
pathologist. Getting permission for this from the couple
requires sensitivity. If a full postmortem examination is declined,
a limited examination of the baby may be acceptable (x ray
examination, computed tomography, blood samples from the
heart area for chromosome analysis, and bacteriological
swabbing of the relevant areas of the body).
Cultural attitudes of the parents influence these decisions
and must be respected. It is probable that the couple will not
object to full histological examination of the placenta.
Philip Steer is professor of obstetrics and consultant obstetrician at
Imperial College School of Medicine, Chelsea and Westminster
Hospital, London.
BMJ 1999;318:1342-5
Treating infections
x Infections manifest themselves by local inflammation (swelling and
tenderness) and a raised temperature
x Treatment is local heat to the area, analgesia, and broad spectrum
antibiotics until the results of bacteriological swabs are available
x Co-amoxiclav and erythromycin are both good choices because
they deal with penicillinase-producing staphylococci and
streptococci, especially group B
x Metronidazole is often added for uterine infections
x If the infection persists, anaemia may follow, which may ultimately
require a blood transfusion
Three levels of psychiatric state associated with childbirth
Postpartum blues (1 in 5 mothers)
x Transient and treatable by reassurance
Puerpural depression (1 in 10 mothers)
x Low mood, lack of energy, guilt, irritability, and insomnia
x Treated by counselling (midwives and health visitors)
x Antidepressantsrefer to GP if depression continues
Puerpural psychosis (1 in 500 mothers)
x Affective, depressive, or manic behaviour; insomnia; confusion;
perplexity
x Refer to psychiatrist and admit to mother and baby unit
Professor Robert Kendell provided help with the section on psychological
and psychiatric conditions. The table showing presenting symptoms in ful-
minating pre-eclampsia is adapted from Sibai et al (Am J Obstet Gynecol
1993;169:1000-6). The cardiotocograph is adapted from Ingemarsson et al
(Fetal heart rate markings. Oxford: Oxford Medical Publications, 1993). The
drawing showing mechanisms of blood clotting is adapted from Letsky
(Obstetrics. London: Churchill Livingstone, 1995).
The ABC of Labour Care is edited by Geoffrey Chamberlain,
emeritus professor of obstetrics and gynaecology at the Singleton
Hospital, Swansea. It will be published as a book in the summer.
Rate
All Wales
0 20 40 60 80 100
South Glamorgan
Powys
Pembrokeshire
Mid Glamorgan
West Glamorgan
Gwynedd
East Dyfed
Clwyd
Gwent
Done
Not requested
Not permitted
Not known
Example of health district data on frequency of perinatal postmortem
examinations and consent sought (data from the Welsh confidential inquiry
into stillbirths and deaths in infancy, 1996)
Radiograph of intrauterine
death showing overlap of
cranial bones after collapse
of fetal skull. Ultrasound
changes after death are of a
more functional nature (lack
of movements or fetal heart
beat) but not so helpful at
showing structural changes
Key references
x Love C, Wallace E. Pregnancies complicated by placenta praevia:
what is appropriate management? Br J Obstet Gynaecol
1996;103:864-7.
x Department of Health. Confidential enquiries into maternal death
(1988-1990). London: HMSO, 1994:43-6.
x Douglas K, Redman C. Eclampsia in the United Kingdom. BMJ
1994;309:1395-400.
x James D, Steer P, Weiner C, Gonik B. High risk obstetrics. London:
Saunders, 1999.
x SANDS (Stillbirth and Neonatal Death Society). Guidelines for
professionals. London: SANDS, 1991.
Clinical review
1345 BMJ VOLUME 318 15 MAY 1999 www. bmj.com